Transitioning from hospital to nursing home (NH) can be a vulnerable time for patients. This study looked for potential associations between adverse events (AE) for NH residents following hospital discharge and NH facility characteristics (e.g., 5-star quality rating, ownership, bed size). Researchers found few associations with individual quality indicators and no association between the 5-star quality rating or composite quality score. Future research to reduce AEs during transition from hospital to NH should look beyond currently available quality measures.

High-risk medications have the potential to cause serious patient harm if not administered correctly. In this randomized trial, a pharmacist-directed intervention (including in-home assessment by a clinical pharmacist, communication with the primary care team, and telephone follow-up) did not result in a lower rate of adverse drug events or medication errors involving high-risk drug classes during the posthospitalization period.

Medication reconciliation and medication regimen reviews can reduce adverse drug events (ADEs) in older adults. This study assessed the impact of a pharmacist-led, patient-centered telemedicine program to manage high-risk medications during transitional and nursing home care. The program included telemedicine-based medication reconciliation at admission and medication regimen reviews throughout the nursing home stay, coupled with clinical decision support. Residents in the program experienced fewer adverse drug events compared to a usual care group. This innovative model has the potential to further reduce medication errors in nursing home residents.

This study randomized primary care practices across ten health care systems to evaluate the effectiveness of a multifactorial intervention to prevent falls with injury, which included risk assessment and individualized plans administered by specially trained nurses. The intervention did not result in a significantly lower rate of serious fall injury compared to usual care.

… needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that …

Patients are frequently encouraged to engage with health care providers as partners in safety by speaking up and sharing their concerns. Although research has shown that patients and family members sometimes identify safety issues that might otherwise go unnoticed, they may not always be willing to speak up. In this cross-sectional study involving eight hospitals, researchers used postdischarge patient survey data to understand patients' comfort in voicing concerns related to their care. Almost 50% of the 10,212 patients who responded to the survey reported experiencing a problem during hospitalization, and 30% of those patients did not always feel comfortable sharing their concerns. An Annual Perspective summarized approaches to engaging patients and caregivers in safety efforts.

… by primary care providers within 24 hours if the provider's InBasket had a high number of notifications at the time of …

… in a Patient Safety Primer and PSNet perspective . … Fisher K, Smith K, Gallagher T, Burns L, Morales C, Mazor K. …

This qualitative study used in-depth interviews with family members of critically ill patients to assess their perception of safety and quality problems. Nearly half of surrogate decision makers identified at least one safety concern, most often relating to communication from clinicians. Patient and family identification of errors is an important strategy for engaging patients in safety efforts.

… Annals of internal medicine … Ann Intern Med … Although patients have been increasingly …

… coordination between providers responding to a patient's telephone call concerns, resulting in an adverse outcome. … make vague references to miscommunication. In a prior WebM&M interview , Dr. Thomas Gallagher, the senior author of this …

Clinical pharmacists retrospectively reviewed ambulatory records to identify adverse drug events following hospital discharge among patients aged 65 years and older. As in prior studies, frequent adverse drug events were found involving a wide range of medications, not limited to potentially inappropriate medications as defined by Beers criteria.

Dementia appeared to be an independent risk factor for medication errors among a cohort of geriatric nursing home patients who were prescribed the anticoagulant warfarin. Increased nursing staff time seemed to mitigate this risk.

This article comments on the patient safety implications of drug shortages and a proposed approach to guide clinical decision-making when distributing medications during shortages.

This study reports on the initial findings of a novel survey intended to evaluate safety culture in nursing homes, the Survey on Resident Safety in Nursing Homes.

This commentary suggests strategies for improving prescribing safety, including linking pharmacy and laboratory data through health information technology.

… significant reduction in adverse events. A past AHRQ WebM&M commentary discusses a case of inadequate warfarin …

This study reports on the development of standards for laboratory monitoring of high-risk medications (such as anticoagulants) in ambulatory care. Pilot testing revealed that the developed guidelines were not being consistently followed, with infrequently prescribed medications most likely to be monitored inappropriately.

… climate in nursing homes. … Castle NG, Wagner LM, Perera S, Ferguson JC, Handler SM. J Patient Saf. 2010;6:59-67. …